1841246303 NPI number — T.M. NICHOLS LLC

Table of content: SAMANTHA RAE GERHARDSON M.D. (NPI 1023540044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841246303 NPI number — T.M. NICHOLS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T.M. NICHOLS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841246303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5825 GLENRIDGE DR NE
Provider Second Line Business Mailing Address:
SUITE 1-112
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-847-9670
Provider Business Mailing Address Fax Number:
404-847-9669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5825 GLENRIDGE DR NE
Provider Second Line Business Practice Location Address:
SUITE 1-112
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-5387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-847-9670
Provider Business Practice Location Address Fax Number:
404-847-9669
Provider Enumeration Date:
05/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARSH
Authorized Official First Name:
BERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
404-847-9670

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  BL05-02072 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)